=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720597339
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CIARAN GEORGE CARROLL FNP, MSN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2017
-----------------------------------------------------
Last Update Date | 01/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15230 LAKESHORE DR
-----------------------------------------------------
City | CLEARLAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-995-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15230 LAKESHORE DR
-----------------------------------------------------
City | CLEARLAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95422-8107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95006668
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------